Eskandar Emad N, Flaherty Alice, Cosgrove G Rees, Shinobu Leslie A, Barker Fred G
Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
J Neurosurg. 2003 Nov;99(5):863-71. doi: 10.3171/jns.2003.99.5.0863.
The surgical treatment of Parkinson disease (PD) has undergone a dramatic shift, from stereotactic ablative procedures toward deep brain stimulaion (DBS). The authors studied this process by investigating practice patterns, mortality and morbidity rates, and hospital charges as reflected in the records of a representative sample of US hospitals between 1996 and 2000.
The authors conducted a retrospective cohort study by using the Nationwide Inpatient Sample database; 1761 operations at 71 hospitals were studied. Projected to the US population, there were 1650 inpatient procedures performed for PD per year (pallidotomies, thalamotomies, and DBS), with no significant change in the annual number of procedures during the study period. The in-hospital mortality rate was 0.2%, discharge other than to home was 8.1%, and the rate of neurological complications was 1.8%, with no significant differences between procedures. In multivariate analyses, hospitals with larger annual caseloads had lower mortality rates (p = 0.002) and better outcomes at hospital discharge (p = 0.007). Placement of deep brain stimulators comprised 0% of operations in 1996 and 88% in 2000. Factors predicting placement of these devices in analyses adjusted for year of surgery included younger age, Caucasian race, private insurance, residence in higher-income areas, hospital teaching status, and smaller annual hospital caseload. In multivariate analysis, total hospital charges were 2.2 times higher for DBS (median dollar 36,000 compared with dollar 12,000, p < 0.001), whereas charges were lower at higher-volume hospitals (p < 0.001).
Surgical treatment of PD in the US changed significantly between 1996 and 2000. Larger-volume hospitals had superior short-term outcomes and lower charges. Future studies should address long-term functional end points, cost/benefit comparisons, and inequities in access to care.
帕金森病（PD）的外科治疗已发生了巨大转变，从立体定向毁损手术转向脑深部电刺激（DBS）。作者通过调查1996年至2000年间美国医院代表性样本记录中所反映的手术模式、死亡率和发病率以及住院费用，对这一过程进行了研究。
作者利用全国住院患者样本数据库进行了一项回顾性队列研究；对71家医院的1761例手术进行了研究。按美国人口比例推算，每年因PD进行的住院手术有1650例（苍白球切开术、丘脑切开术和DBS），研究期间手术例数无显著变化。住院死亡率为0.2%，非回家出院率为8.1%，神经并发症发生率为1.8%，不同手术方式之间无显著差异。在多变量分析中，年病例数较多的医院死亡率较低（p = 0.002），出院时预后较好（p = 0.007）。脑深部刺激器植入术在1996年的手术中占0%，在2000年占88%。在根据手术年份调整的分析中，预测这些设备植入的因素包括年龄较小、白种人、私人保险、居住在高收入地区、医院教学状况以及年医院病例数较少。在多变量分析中，DBS的总住院费用高出2.2倍（中位数36,000美元，而其他手术为12,000美元，p < 0.001），而病例数较多的医院费用较低（p < 0.001）。
1996年至2000年间，美国PD的外科治疗发生了显著变化。病例数较多的医院短期预后较好且费用较低。未来的研究应关注长期功能终点、成本/效益比较以及医疗服务可及性方面的不平等问题。
